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Necrotic Araneism. A review of the Loxosceles Genus. II. Clinical findings, diagnosis and treatment.


Skin loxoscelism

Often times, spider bites go unnoticed [1]. In general terms, the victim feels no pain for the first 2-3 hours [2]. On certain occasions (20%) [3,5], it only causes transitory pain, reddening and local swelling (marmoreal plaque in the form of a volcano [6,7]) in the first 10 minutes [8]. On the average, the victim requires medical care after the first 3-8 hours, when the pain and itching are intense (a burning sensation is felt) [9,11]. There are two types of skin loxoscelism, the necrotic (75%) and edematous (4%) [5]. The signal that identifies the bite are two micro punctures (points) separated at least by 6 mm [12]. In mild cases, the local reaction is erythema and edema with an itching sensation [13,14]. The edematous appearance, depending on the severity, is characterized by an edema of extraordinary dimensions with a minor component of necrosis and erythema (in general, the godet sign is negative) and is the best prognostic tool [15,17]. Frequently, it extends to downward surfaces, a phenomenon seen when bitten in the face, neck or sectors proximal to the extremities [17]. The intense inflammatory response is mediated by arachidonic acid, prostaglandins and the chemotactic infiltration of neutrophils which is amplified by the intrinsic vascular cascade that involves the reactive protein C and the activation of the complement [9]. After 6-8 hours, the affected area is painful and itchy, showing a central indurate area surrounded by a pale ischemic zone and another exterior erythematous section that conforms the typical bull's-eye sign (red-white-blue) [18,20], a liveloid plaque (purple stain) secondary to the gravitational dissemination of the venom (Figure 1) [5,9,21].


In the majority of the cases, the lesion disappears without treatment after 2-3 days [1,14,23]. For the first 24-72 hours [24], fever of variable intensity may occur, with chills, weakness, nausea, vomiting, muscle pain, joint pain, rash, sleep disorders and petechia together with leukocytosis and thrombocytopenia [25,27]. It may be similar to having influenza [28]. In order of importance, the arms, legs, neck or lower part of the abdomen are the anatomical regions mainly affected [3,14,16]. However, the majority of the times the victims seeks medical care after some time [3]. Over 80% of the patients see their physician six hours after the bite and almost 60% does it after 12 hours [29].

In severe cases (approximately 10%) [18], in a lapse of 24-48 hours, the erythema disseminates and the center of the lesion appears hemorrhagic, necrotic and with a flictena in the upper part, of serous or serohemorrhagic content [13,14,17]. Peripheral necrotic areas (satellite ulcers) with hemorrhages may form [1] without involving ganglia [17] and later skin, subcutaneous tissue or even muscle destruction [25,28,30]. Necrosis is significant in areas with fat as in the gluteus, thighs and abdominal wall [9]. A black scab forms, which falls off after several weeks with large tissue loss, leaving several residual ulcers of 1-25 cm in diameter [14,31]. Finally, about three weeks are needed for a wide and depressed (deformed) scar to form, time during which pain is of importance [1,14,25]. Healing takes place 3-6 months later but may continue for up to three years if there is extensive affection of adipose tissue.

Skin-visceral Loxoscel ism (Systemic Loxoscel ism) (SVL)

Systemic reactions are severe (14-22%), with several deaths being reported [16,21,32]. Acute cases that place lives in danger generally limit themselves to children with manifestations such as intravascular hemolysis, anemia, hemoglobinuria, hematuria, hyperkalemia, petechia, jaundice, high fever (39.7-42.0[degrees]C) [17], nausea, vomiting, joint pain, muscle pain, chills, hypotension [22], seizures, kidney failure (oliguria/anuria), hypercatabolic syndrome [33], multiple organic failure, respiratory distress [34], pulmonary edema and shock [1,14,21,25], maybe due to a lesser body area venom distribution [16]. Classically, there will be slight macular erythema (exanthema) on the chest and extremities [35]. When there is visceral involvement, massive hemorrhagic lesions are seen in the liver and kidneys. Shock and anaphylaxis are seen in severe cases, especially in children, the elderly and weak patients [3,36]. Kidney failure can be induced by disseminated intravascular coagulation, but also seems to be linked to the action of metallo-proteins that degrade the extra-cellular matrix and damage the integrity of the basal membranes of the kidney's blood vessels [5]. The majority of the cases of SVL (73.5%) show signs indicative of hemolysis within the first six hours of evolution [29]. The blood abnormalities include hemolytic anemia, thrombocytopenia and leukocytosis [16]. Urine is often walnut brown [17]. Other risk factors related to this type of presentation are: chest and abdominal bites, fever, nausea and vomiting in the first 24 hours [33].

Among the results of loxoscelism are: 1) death, almost exclusively restricted to skin-visceral or visceral-hemolytic cases (15%), is also related to massive hemolytic anemia associated to acute renal failure. In the Chilean series, 23.5% mortality has been reported in this group of patients and 3.7% of the total cases of loxoscelism. In relation to the temporary handicap, in the majority of those affected, the disease resolved within the first three weeks, although there are cases that may extend for six or more weeks [5,29,33]. In general, recovery of an attack leaves behind complete systemic immunity against subsequent accidents, although there may be an intense local reaction with skin loss [37].


Approximately half evolve and form a necrotic scab. Of these, two thirds become ulcers; the majority heals spontaneously without leaving sequelae. Only 8% evolve and form a keloid scar. The proportion of patients that develop ulcers (approximately 50%) is greater in those that develop a liveloid plaque from the start, than those with an erythematous plaque (16 %). Consequently, the final evolution to a scar with sequelae is proportionally greater in individuals with a liveloid plaque, in comparison to those with an erythematous plaque (approximately 12% vs. 3%). The exception could be the predominantly erythematous form--edema as the only skin manifestations, especially in facial accidents--but the scarcity of cases does not allow scientists to reach a conclusion. Palpebral lesions have been described that often require grafts (Figure 2) [22,38].

Myonecrosis, pseudoepitheliomatous hyperplasia and gangrenous pioderm are often seen as complications [6]. Diaphragmatic paralysis is rare [39]. Other local sequelae include lesions to the nerves and secondary infections (Figure 3). The presence of Clostridium perfringens is associated to the necrotic process. All of the forms of skin loxoscelism are painful to the touch [22,38].


Anamnesis is important in searching for the geographical location of the accident (rural or urban area), whether domiciliary or peridomiciliary, time of day, place of work, activity carried out at the time of the bite, animal characteristics if seen, whether the spider is caught, history of bites or stings by other animals, addictions, allergic and pathologic history, etc. [40].

No laboratory tests exist that confirm diagnosis. Its diagnosis is eminently clinical and necessary for the identification of the arachnid [15,21]. The spider is seen in 80% of the cases and identified in 13% [5]. Nonetheless, there is a need to determine and monitor hemolysis data, conducting a hemogram for platelet count, prothrombin time (PT), partial prothrombin time (PTT), kidney function (urea and creatinine) and serum electrolytes (especially potassium) [20,21]. The urinalysis may show some evidence of systemic involvement (hemoglobinuria, myoglobinuria, hematuria). Gram stain and wound culture should be done on wounds for identifying contaminating microorganisms [9,41]. Similarly, hepatic functionality test, fibrinogen and fibrin degradation products should be measured [16].

If treatment with dapsone is considered, G-6-PD levels should be measured [9]. The ELISA-specific passive hemaglutination inhibition test has been developed for detecting the venom at the site of the bite and IgG-specific in serum, although none is available in the clinical practice [6,16]. Similarly, there is a fast ELISA test for detecting the venom in skin and hairs up to four days after the bite [42]. There are crossed reactivity tests for the Loxosceles venom and from other arthropods with similar poisoning strategies, with sensitivity for detecting up to 40 ng [43]. The differential diagnosis should be done with problems that cause similar lesions (Table 1).


General Measures

The initial management is antisymptomatic and consists in cleaning the wound locally (washing with cold water and mild soap), placing colds pads or ice, sterile bandage, avoiding or decreasing physical activity, elevating or mild immobilization of the affected area (RICE). Do not apply tourniquets [6,31,44]. Hot pads on the affected area must be avoided (this may accelerate tissue destruction), as well as lotions with steroids, nor remove the venom using suction, incisions or electrotherapy [20,45] . Since the action of sphingomyelinase D is dependent on temperature (more active at 37[degrees]C) the use of cold pads should be continued until the progression of the necrotic process is stopped [9]. If necessary, administer analgesics, antihistamines (in skin cases), hemorrheologics (pentoxifilin), antimicrobials and a tetanus shot [13,14,30,33]. Solutions and dextran may be used if the patient so requires [1]. Chloropheniramine is indicated at a dose of 5-10 mg/tid/i.v. for 2 days (0.4 mg/kg/day/qid) and 10 mg every 8, 12 or 24 hours v.o. [3] or dextrochlorophenamine at a dose of 0.15 mg/kg/day for the time necessary until the disappearance of pain, edema and the delimitation of necrosis [5]. Hydroxicin, at a dose of 25 mg/tid/vo is effective if there is morbiliform rash and itching [9]. Diphenhydramine is used at a dose of 50-75 mg/v.o./i.m. in adults and 1-2 mg/kg/v.o./i.m. in children [9]. Morphine and other opium derivatives should be avoided since they can increase the effect of the venom [36]. Insufficient data to justify the use of nitroglycerin is unavailable [9]. Tetracycline, a metalloproteinase inhibitor, may help in avoiding cell death and the subsequent destruction of tissues [46].

Recently, importance has been given to the use of dapsone and cholchicin [4,26], inhibitors of polymorphonuclear leukocytes [21]. If the local reaction progresses rapidly or ulcers appear, dapsone is administered orally at a dose of 50-200 mg/bi/10-25 days [5,6], previous exclusion of a deficit of glucose-6-phosphate dehydrogenase [13,14,31,35]. The pediatric dose is 1-2 mg/kg/d/v.o. without exceeding 100 mg/d [9]. Precaution must be taken with collateral effects such as general malaise, nausea and hemolysis that may be confused with the systemic effects of the venom [47]. Cholchicin is administered at a dose of 1.2 mg/v.o., followed by 0.6 mg/2 h/2 days and then 0.6 mg/4 h/2 days more [5]. Previously, in persons bitten by spiders (or by unidentified species) that develop skin lesions within the first 12 hours and that increased in size during the following 12 hours, dexamethasone is recommended at a dose of 4 mg/quid/i.m. during the acute phase and then in decreasing doses based on standard practice [30]. The parenteral route is preferred due to the affection of the gastrointestinal mucosa which would damage the absorption of drugs [17]. Low doses of aspirin (100 mg/day) are recommended [48].


Patients will remain under observation at hospitals when they have a rapid expansion of lesions or have evidence of systemic toxicity which requires conservative wound care, immobilization, elevation and proper treatment if a bacterial infection occurs [9]. The skin-visceral cases require hospitalization for proper antishock and antitoxic management, carrying out the rigorous handling of fluids and electrolytes, with an indication of blood transfusion when necessary [5,9]. Although the efficacy of local or systemic glucocorticoids has not been demonstrated [1,14], when used they are administered immediately to counteract severe reactions [13,36] (80 mg of methylprednisone/i.m./during transportation to the hospital [34]); hydrocortisone succinate (1g/qid/i.v./48 h, later continuing, if necessary, with prednisone 40-100 mg/v.o. (1-2 mk/kg/d), once a day during the mornings for four to five days, in decreasing amounts of 10 mg/d associating it with an antihistamine orally administered [49,51]. A short oral scheme of prednisone may decrease hemolysis. Methylprednisone is administered at a dose of 2-60 mg/d and 1 mg/kg/d/v.o. in adults and children, respectively [9]. Another scheme is that of 80 mg/d/i.m. immediately after the bite, continued for a week and with decreases of 40 mg, 20 mg and 10 mg/d for a total of 10 days [34]. If there is anaphylactic shock, adrenaline is injected at 1:1000 s.c. at the dose and frequency based on the severity and response [49, 50, 51]. In case of severe hypotension or shock: adrenaline 0.3-0.5 mg/s.c. (with local massage to improve absorption), 11 mg/i.m. for adults and 0.001 mg/kg to a maximum of 0.3 mg in children. The dose can be repeated after 10-15 minutes based on evolution. In severe cases an ampulla of adrenaline can be used (1 mg/i.v. diluted in 9 c.c. of physiological solution in bolus repeated in 2-3 ml, equivalent to 0.2-0.3 mg [48].


Heparin's real use has not been proven [1]. Satisfactory results were achieved through hemodialysis and/or peritoneal dialysis in patients with skin-visceral loxoscelism [17].

After 72 hours a urinalysis and complete blood count to detect any evidence of systemic toxicity is recommended. In case of fever or dark urine, the patient must return to the hospital immediately [9].

Surgical Procedure

Certain authors recommend the surgical excision of the wound as soon as possible [26], preferably within the first 24 hours [1,25]. Others mention that this may be damaging and that the debridation as well as the use of a skin graft is recommended after the acute inflammation subsides, once necrotic damage is extensive [14,35,36]. If the necrotic tissue is to be removed, this must be extensive, with daily wound washings using saline solution until granulation is achieved [3]. Preferably, a conservative debridement should be done, once the wound margins are well-defined, since a wider excision may be disabling, disfiguring and rarely indicated [9]. Only 3% heal with scars that require excision [52].

Occasionally, the intervention of a plastic surgeon is required, especially in extensive areas with dermonecrotic compromise [53,55]. When a total thickness defect is caused, the definite surgical treatment involves a skin graft or a total flap, depending on the base area and its extension [56].


Initially, the wound is not infected for the first two or three days, but may become contaminated when the patient scratches the wound due to intense itching [57].

Others proposed indications are: daily washing of the ulcerate wounds with 3% oxygenated water, submerging in Burrow solution at 1:20/tid for 15 minutes or apply a triple watery coloring (brilliant green 1:400, genciana violet 1:400 and acriflavin 1:1000) three times a week, as in the case of crotale bites.

The use of ointments containing polymixin, neomycin and bacitracin during the evenings is also recommended [30].

If an additional infectious process is suspected, due to the slow evolution of the dermonecrotic process, this makes it inclined to Gram positive microorganisms (streptococci and staphylococci) attraction, considering the use of cloxacylin, flucloxacylin, cefalexin, oral penicillin or clindamycin necessary. Gram negative agents and anaerobes are less frequent [58,59]. The use of erythromycin prophylactically is universally accepted to avoid additional wound infections [56]. In 11 cases of children, the administration of dicloxacylin plus dapsone 1 mg/kg/d was effective, since none evolved systemically [60].


If in some countries the development of antidotes against the Loxosceles venom has started they have not been approved for their use due to the lack of satisfactory clinical assessments. Nonetheless, 10 ampoules of antiloxoscelic serum/i.v. [4,14,25] are recommended. In Brazil, a polyvalent hyperimmune ecquine serum is used against Phoneutria nigri venter, Loxosceles gaucho, Tityus serrulatus and T. bahiensis (scorpions) [36,61], indicating that 1 ml neutralizes less than 6 necrotizing minimum doses and 1 ml of lexoscelic serum (made from L. intermedia) for 15 DMN [61]. The monovalent antisera derived from different Loxosceles species share their abilities for neutralizing the dermonecrotic activity. Particularly, those produced from L. intermedia and L. gaucho maintains their properties when faced with L. laeta [29].

In Peru, depending on the severity of the case, the dose recommended for children as well as adults is 1 or 2 ampoules of antiloxoscelic serum/s.c. in the interscapulary zone or i.v. at a 1:3 dilution with physiologic serum [40].

In Mexico, a technique named Fabotherapy (portions of Fab2 of immunoglobulins) has been developed and perfected with a high level of specificity neutralizing venoms while avoiding adverse reactions of first and second generation sera [62]. It is suggested that the application of the antiloxoscelic serum as soon as possible within the first 2-4 hours after the accident is the best measure possible, which is not always easy. In cases of skin loxoscelism, 5 ampoules/i.v. are applied and 5-10 ampoules for the skin-visceral form [5,6,17] . The polyvalent phototherapeutic antiarachnid (Latrodectus and Loxosceles) by slow i.v. or i.m. at a dose of 5-15 ml (one to three bottles), that can be increased depending on the severity, possesses the neutralizing ability of 6,000 [LD50.SUB.[63]]. Currently, Bioclon-Silanes produce a specific fabtherapeutic to counteract the poisoning of the Loxosceles (Loxmyn), obtained from recombinant toxins from spiders from the United States, Mexico and Peru that may be useful against the "violinists" from the American continent [64].

The only mention on adverse events is found in the Brazilian series from Santa Catarina reporting 6.5% (8/125) reactions catalogued as mild: skin rashes, facial rubor, nausea and vomiting, rash, chills and bronchial spasm [29]. From the antidote of hyperimmunized equine, the reactions are of the anaphylactic type and anaphylactoid and occur in a higher frequency in persons treated with the product [22].

Indications for applying the biologics are: 1. the aggravating animal is a spider with morphological attributes to the Loxosceles genera; 2. the patient does not have the arthropod but refers that the bite was by a spider within the home and has loxoscelism manifestations; 3. the subject does not pinpoint the origin nor the circumstances that made the accident possible but the place where it presumably started points to spider webs, or identifiable spider remains; 4. without any data, the victim reveals a clinical pattern compatible with loxoscelism, and 5. in all severe clinical presentations [40].

Results and discussion

If in the majority of the cases of arachnidism, the spider is not identified, it has been currently seen that a greater number of people develop necrotic ulcers probably due to the great variety of species found distributed throughout the Mexican Republic or even the introduction of dangerous species such as L. recluse and L. laeta that cause severe poisoning in the United States and South America. As the attacks usually occur, the bite is produced accidentally when dressing or sleeping with no differences found in gender. Therefore, since the lesions produced by the "violin" spider bites are unspecified, the following observations should be considered for a definite diagnosis: potential exposure to these spiders, their detailed identification, the characteristics of the lesions and the clinical course [18], due, it is known that the poison from other genera such as Phoneutria, Lycosa, Tegenaria and Chiracanthium contain necrotoxins


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(1) Hector Gabriel Ramos Rodriguez and (2) Jose D. Mendez

(1) Medical Gerontology Module. "Tlalpan" Family Medicine Clinic, ISSSTE, School of Geography. Faculty of Philosophy and Letters, National Autonomous University of Mexico (UNAM)

(2) Medical Research Unit in Metabolic Diseases, 21st Century National Medical Center, Mexican Institute of Social Security P.O. Box A-047, 06703 Mexico City, D.F., Mexico.

Corresponding Author

Jose D. Mendez, 21st Century National Medical Center, Mexican Institute of Social Security P.O. Box A-047, 06703 Mexico City, D.F., Mexico.

Telephone Number: +52 55 5627 6900 ext. 21561 Fax Number: +52 55 5227 6109 E-mail:
Table 1: Pathologies that cause similar necrotic lesions to those
produced by Loxosceles

Pyoderm ias (Staph. Poison ivy Thromboembolic
 and Strept.) phenomena
Lyme disease Poisonous oak Chemical burns
Herpes simplex Gonococci derm Nodule erythema
Diabetic ulcer Rocky mountain fever Warfarin poisoning
Worm bites Stevens-Johnson Heparin poisoning
Acarus bites Lymphomatoid Nodule
 papulosis periartheritis
Tick bites Sporotrichosis Multiform erythema
Wasp sting Adverse reactions Toxic epidermal
 to drugs necrolysis
Fly bites Herpes zoster Pressure ulcers
Bites by other Lymphomas Skin mycosis
Focal vasculitis Fulminant purpura Squamous cell
Syphilitic chancre Anthrax Varicose ulcers
Chickenpox Trauma Necrotizing fascitis
Angioneurotic edema Skin lupus Erysipela
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Title Annotation:Original Article
Author:Rodriguez, Hector Gabriel Ramos; Mendez, Jose D.
Publication:Advances in Environmental Biology
Article Type:Report
Date:Jan 1, 2008
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Next Article:Necrotic Araneism a review of the Loxosceles Genus. III. Prevention, control and case reports.

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